Complaint Investigation Report, 01/09/2025

Hospital medical records document on 03/09/2022 R1 was transported to a local hospital and was diagnosed with an angulated overriding right intertrochanteric fracture. Staff provided inconsistent accounts of the incident surrounding R1’s fall. The licensee reported live-in night shift staff, Staff 1 (S1), sleeps throughout the night. S1 will check on residents at 2300 hours and then sleeps until morning when residents start to awaken between 0630 and 0700 hours. S1 corroborated this and indicated they do not check on residents unless summoned by residents. Staff interviews revealed AM staff arrive at 0700 hours. Staff 2 (S2) reported finding R1 at 0700 hours on 03/09/2022 on the floor of R1’s bedroom. S2 was unaware of how long R1 was on the floor before being found. The licensee corroborated being called to R1’s bedroom by S2 at 0700 hours and finding R1 on the floor. S1 reported they slept at the facility but were not “on duty” the day prior and the day of the incident. There were no other staff present during the night shift. S1 reported even when they are off duty they would listen for residents and assist them if needed. S1 reported they did not observe or hear anything unusual the night of the incident.

Staff consistently reported R1 required assistance of wheelchair and walker when ambulating. However, staff keeps these devices out of eyesight, so R1 is not tempted to access the devices independently. During a visit by Department staff on 06/13/2022, the Department staff observed R1’s wheelchair to be placed out of sight of R1 approximately 10 feet away.

The Desert Cottage Program Plan documents, “at least two caregivers will be available to the residents at all times.” Facility Admission Agreement for R1, dated 05/17/2021; documents R1 is receiving Level 2 services which are for residents that rely on the facility for extensive assistance with personal activities of daily living and includes residents who are a fall risk or have declining mobility. Basic services in the admission agreement include continuous care and supervision.